specific IPA services

You are a hospitaladministrator at University Hospital, responsible for making sure that every physicianwho admits a patient with a benefit plan provided by an IPA is contacted to make sure that the plan will cover the services, whether itâ??s a visit to the Emergency Department for a broken arm or a referral to an orthopedist to do the surgery. This is hard to do, because every IPA has a different list of approved facilities, providers, and services covered and University Hospital has discovered that if the physician doesnâ??t figure this out ahead of time, the Hospital doesnâ??t get paid. Even if physicians have to be called at an inconvenient time, it is critical that these benefits get figured out before the patientâ??s admission officially starts.

Today, one of the general medicine doctors has stormed into your office demanding to see you. Angrily, she snaps at you: â??My phone rang at 3:15 this morning because your emergency department had to know if my patient, Buster Lovegood, could be admitted with a severe leg injury based on his IPAâ??s coverage policies. I havenâ??t seen Buster in a year and I certainly donâ??t take his medical record and insurance information with me when I go to bed. After I told them, â??Of course,â? they called me back a half an hour later just to tell me that he had a displaced tibia fracture and which orthopedist did I want to see him? I donâ??t know who is on the IPA list of â??approvedâ?? surgeons and I told them to figure it out. Then, I got another call from Buster at 6:00 this morning, telling me that the orthopedist who took care of him last night isnâ??t on the â??preferredâ?? list. It took me and my office manager two hours this morning getting approval from the IPA for a non-network orthopedic emergency room consult. Then we had to call four different orthopods who were on the â??listâ?? to get one who could see Buster today â?" and then it took 7 more calls to get the IPA to give us the authorization numbers and patient instructions so he doesnâ??t have to pay through the nose! This is crazy â?" what are you going to do?!!â?

Question: What are some of the issues that need to be dealt with, and who needs to be involved?

Are the issues as black and white as the general medicine doc made it out to be?

What are the â??shades of greyâ? that should be recognized, if any?

Solution Preview

University Hospital needs to develop a database that provides easy and quick access to health care providers at all levels, to keep information on network physicians, approval contact numbers and other information about specific IPA services close at hand. A database that includes information from each IPA will help those on site at the hospital determine which physicians, specialists will be covered and how to access the IPA quickly. For on-call physicians, the contact person who makes the call can access the database and provide the physician with the information, when the physician is at home or away from the hospital. Such a database should also be formatted so that it is compatible with portable digital devices, such as iPhone and PDA. In order to develop such a ...

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